Pleomorphic Adenoma of the Palate: Diagnostic and Surgical Strategy

Pleomorphic adenoma is a benign tumor of the salivary glands. It develops preferentially in the parotid gland. The authors report a localization of a pleomorphic adenoma on the palate and discuss the value of CT scan in therapeutic strategy.


Introduction
Pleomorphic adenoma is a benign tumor of the salivary glands.It occurs predominantly in the parotid gland (80%), followed by the submandibular gland (10%) and the accessory salivary glands (10%) [1].Among pleomorphic adenomas of the accessory salivary glands, localization to the palate accounts for 60%, followed by the upper lip 20% [2].We report a case of pleomorphic adenoma of the hard palate and discuss diagnostic and therapeutic aspects.

Case Report
A 27-year-old female patient consulted the department of ENT for a swelling of the palate that had been evolving for 3 years, progressively increasing in volume without any troublesome symptoms.
Local examination revealed a hard, ovoid, painless mass of the palate with a frm consistency, approximately 3 cm long, with a healthy mucosa.Tere were no lymph nodes.Te patient's general condition was good.
A CT scan revealed a dense, rounded mass located on the hard palate (Figure 1).Tere was no bone destruction.We did not perform fne needle aspiration.Because of the absence of clinical signs of malignancy, we opted for surgery.
Te palate mass was removed under general anaesthesia (Figures 2 and 3).Postoperative follow-up was normal.Histology of the operative specimen showed a pleomorphic adenoma of the palate (Figure 4).

Discussion
Pleomorphic adenoma of the palate is a mixed benign tumor of the salivary glands of the palate mucosa.It represents 60% of pleomorphic adenomas of the accessory salivary glands.It occurs most frequently in women between the ages of 20 and 79 [3][4][5][6].In the current study, the patient was younger, she was 27 years old.
Te symptoms depend on the size of the tumor.When smaller than 6 cm, it is asymptomatic.At most, minor signs such as itching, chewing difculties, or slight pain have been described [7].Untreated, the size can exceed 9 to 10 cm and compromise respiratory, digestive, or phonatory functions, as reported by Andrea Bordoy-Soto et al. [2].
On physical examination, the pleomorphic adenoma typically presents as a smooth mass, frm in consistency, fxed in relation to the superfcial and deep planes, covered by normal mucosa [3,[8][9][10].
Imaging like CT scan and MRI provides information on the exact location, size, surface and deep extension of the tumor [11].CT scans are more accessible and can be used to study bone involvement.MRI better determines soft tissue extension.
Fine needle aspiration is often used to diagnose tumors of the main salivary glands.Te oral cavity is easily accessible, so FNAC could be used to diagnose adenomas of the palate.Coupled with MRI, the two results would allow a histological orientation of pleomorphic adenoma.So Sunil et al. suggest that the main diagnostic methods are a combination of FNAC and imaging like CT scan and MRI [12].
Biopsy under local anaesthesia is more invasive than FNAC but allows a histological examination.Trocar biopsy can be reserved for cases where the results of cytology are indeterminate.Tis was the case of Antonios et al., who reported a case of pleomorphic adenoma of the palate which was not confrmed by the FNAC [11].
For the surgeon, having a cytological or histological orientation helps to adopt an appropriate surgical strategy.
Indeed, in terms of treatment, wide surgical excision, including the surrounding capsule, periosteum, and mucosa, is the treatment of choice for pleomorphic adenomas of the palate.Enucleation is not recommended because high recurrence rate are noted [12,13].Case Reports in Otolaryngology In our patient, as in case of Zayd [14], we did not have a histological orientation, which is the reason why we preserved the mucosa adjacent to the mass, whereas resection of the mucosa is recommended to reduce the risk of recurrence.Tis attitude was adopted by some authors who had preoperative cytological or histological indications [13,15].
Tus, to avoid recurrence, excision should be followed by curettage of the underlying bone using a sharp spoon or bur under copious irrigation with sterile normal saline [16].However, bone curettage is not justifed in the absence of bone erosion on CT scan, as in our patient's case.Patigaroo et al. described a case of maxillectomy for a palatal adenoma extending into the maxillary sinus [7].CT scan is an indispensable tool for improving surgical strategy by studying bone involvement.
After resection of the adenoma, the defect on the palate can be repaired with a local fap or allowed to granulate [17].
At the end, we note that surgical attitudes are diferent from one surgeon to another.
Table 1 summarizes diferent surgical approaches.However, wide excision seems to be a consensus reported by all authors and postoperative follow-up is often simple.

Conclusion
Pleomorphic adenoma is a recurrent benign tumor, so long-term follow-up is essential.A preoperative cytology or histology and CT scan are essential for a better surgical strategy.

Table 1 :
Summary of diferent surgical approaches.